Brain death and donor management in the intensive care unit: experiences over the last 3 years

Coding the Dead: Cardiopulmonary Resuscitation for Organ Preservation

BACKGROUND

There is lack of consensus in the bioethics literature regarding the use of cardiopulmonary resuscitation (CPR) for organ-preserving purposes. In this study, we assessed the perspectives of clinicians in critical care settings to better inform donor management policy and practice.

METHODS

An online anonymous survey of members of the Society of Critical Care Medicine that presented various scenarios about CPR for organ preservation.

RESULTS

The email was sent to 10,340 members. It was opened by 5,416 (52%) of members and 405 members (4%) completed the survey with few missing data. A majority of respondents (81%) answered that donation status should not influence whether CPR is performed on an imminently dying patient. There was very strong agreement (>85%) that 1) CPR should be performed on a registered donor who experiences a cardiac arrest with an unknown code status before death by neurological criteria (DNC) and 2) CPR should be performed if the patient is not a registered donor and experiences cardiac arrest but the surrogate/power of attorney (POA) has not yet been approached regarding code status and donation. When a registered donor with a DNR order experiences cardiac arrest before DNC, 98% of respondents would not perform CPR. However, after DNC, respondents were evenly divided on whether they would (49%) or would not (51%) perform CPR on a registered donor with an undocumented code status. When asked whether consent should be required for CPR for organ-preserving purposes, 39% answered "Yes" when a patient arrests before DNC and 48% answered "Yes" when a patient arrests after DNC (P = 0.2).

CONCLUSIONS

The majority of respondents did not consider donor status relevant to CPR decisions before DNC, and virtually all would respect a DNR order in a registered donor before DNC. Respondents were divided about the need for an affirmative consent for CPR for organ-preserving purposes both before and after DNC.

Changes in Clinical Features and Demographics in Donors After Brain Death Over the Past 20 Years: A Single-Center Experience in the Republic of Korea

OBJECTIVES

We investigated clinical characteristics and demographics of brain death in patients from a single center in Korea to identify possible changes in organ procurement by comparing early and late periods.

MATERIALS AND METHODS

Potential donors diagnosed as brain dead and who had provided organ donation consent from May 2000 to May 2020 were considered. Donors were divided into 2 categories: early period (2000-2010) and late period (2011-2020).Demographic data, clinicalrisk factors, cause of death, use ofinotropic and vasoconstrictor agents, laboratory findings, intensive care unit stay data, loss of donors, and number of donated organs were analyzed.

RESULTS

Mean age of donors significantly increased in the late period (36.0 ± 12.0 vs 46.0 ± 15.1 years), but there were no significant differences in the proportion of females and the number of pediatric donors (<18 years). The number of donors who smoked decreased (61% vs 41%), but hypertension rate increased significantly in the late period (17.4% vs 31.0%). In the late period, fewer brain dead donors were lost (19.0% vs 7.59%) and use of vasoconstrictor agents was more frequent (25.3% vs 64.5%) than use of inotropic agents (73.1% vs 49.3%). In the late period, heart(19.0% vs 37.3%) and lung (0% vs 18.3%) procurement rates increased and the number of transplanted organs per donorincreased (2.58 ± 1.6 vs 3.14 ± 1.50; P = .016). Causes of death were primarily from head traumas (34.4%), cerebral aneurysms (21.7%), spontaneous intracerebral hemorrhage (21.3%), and asphyxia/hanging (16.3%). Head trauma decreased in the late period (46% vs 29.7%; P = .021) but still constituted the most common cause of death.

CONCLUSIONS

We found no definite demographic changes in brain dead donors. Donors with cerebrovascular disease increased annually, but trauma was still the most common cause of brain death, with suicides being highly frequent.

Hypothalamic function in patients diagnosed as brain dead and its practical consequences

Some patients who have been diagnosed as "dead by neurologic criteria" continue to exhibit certain brain functions, most commonly, neuroendocrine functions. In this chapter, we review the pathophysiology of brain death that can lead either to neuroendocrine failure or to preserved neuroendocrine functioning. We review the evidence on continued hypothalamic functioning in patients who have been declared "brain dead," examine potential mechanisms that would explain these findings, and discuss how these findings create additional confounds for brain death testing. We conclude by reviewing the evidence for the management of hypothalamic-pituitary failure in the setting of brain death and organ transplantation.

Approach of the Clinicians Practicing in Intensive Care Units to Brain Death Diagnosis and Training Expectations in Turkey: A Web-Based Survey

BACKGROUND

For health professionals, recognizing and diagnosing brain death is vital for the development of organ transplantation. However, cadaveric organ donation rates remain insufficient, and this problem has become one of the most serious obstacles in the treatment of end-organ failure.

OBJECTIVES

This study examines the attitude and knowledge level of clinicians who practice in intensive care units (ICUs) concerning the determination of brain death and describes the hindrances in diagnosing brain death.

MATERIALS AND METHODS

A survey study was designed with 26 questions, including questions regarding the determination of characteristics of respondents' trainings, practicing preferences, and their knowledge and approach toward brain death diagnosis. Clinicians practicing in ICUs in Turkey were invited to the survey.

RESULTS

A total of 244 surveys were fully completed. Physicians working at the university hospitals or university-affiliated hospitals answered the basic knowledge questions about brain death more accurately (P < .001). Also, physicians employed in university or university-affiliated hospitals feel more capable in diagnosing brain death (P = .002) and are more willing to receive education on the brain death issue (P < .001).

CONCLUSION

There is a gap separating the practices suggested in guidelines and the daily practice of ICU clinicians working in state hospitals or private institutions. Academic organizations producing and leading the education curricula may assist in informing ICU clinicians who should be trained.

A Bibliometric Analysis of the Articles Focusing on the Subject of Brain Death Published in Scientific Citation Index-Expanded Indexed Journals: Analysis of 3487 Articles Published Between 1995-2019

BACKGROUND

Although the topic of brain death (BD) has been increasing in popularity considerably in recent years by the snowballing number of patients suffering from end-organ failure and waiting for organ transplantation, the literature indicates insufficient information regarding the comparison of scientific articles focusing on BD, authors' and nations', even governments' tendency about this issue.

OBJECTIVES

In the present study, we aimed to make a bibliometric analysis of the articles focusing on the subject of BD, which is one of the most trendy topics in organ transplantation.

MATERIAL AND METHODS

The terms "brain death," were searched in Thomson Reuters, Web of Science search engine for the years between 1995 and 2019. All the articles found were subjected to bibliometric analysis.

RESULTS

Web of Science database included 3487 articles. The United States was found to be the most productive country in all methods, and Transplantation Proceedings was the journal that contributed most to the literature on the subject of BD. A positive correlation between publication productivity and gross domestic product/gross domestic product per capita and human development index was found (r = 0.470, P < .05; r = 0.359, P < .05; r = 0.603, P < .001, respectively). Also, there was a negative correlation between the number of published articles and the population of the country (r = -0.083, P < .001).

CONCLUSION

Although the top country focusing on the subject of BD was the United States in terms of bibliometrics, we found that there is a correlation between the indices measuring the welfare and development level of the country and publication productivity about BD, which means developed countries show more tendency about BD, which is the main component of the definitive treatment of end-organ failure.

Global Scientific Outputs of Brain Death Publications and Evaluation According to the Religions of Countries

In 1950s, the concept of brain death, which began to be discussed primarily in terms of medicine and then in terms of religion, law, and ethics, became a central topic in all world countries as it was an early diagnosis of death. Despite the fact that brain death (BD) diagnosis is of importance for benefitting from organ and tissue transplantation of patients in the world, the literature still involves no bibliometric studies that made a holistic evaluation of the publications about this issue. The present study aims to investigate the top-cited articles about BD published between 1980 and 2018, identify the citation collaboration of the journals, demonstrate the collaboration between the countries, define the relationship between organ transplantation and BD, and reveal the latest developments and trend topics about this issue. In addition, this study aims to investigate the relationship between religions of countries and brain death publication productivity. Documents for bibliometric analysis were downloaded from Web of Science. The literature search was performed using the keywords "brain death/dead" during 1980-2018. The correlations between gross domestic product (GDP), Human Development Index (HDI) and publication productivity of the countries on BD were investigated with Spearman's correlation coefficient. There was a high-level, statistically significant correlation between the number of publications and GDP, and HDI and the number of publications about BD (r = 0.761, p < 0.001; r = 0.703, p < 0.001). The USA was the top country in terms of publication productivity, which was followed by developed countries such as Germany, Japan, France, and Spain. However, the contribution of the undeveloped or developing countries such as China, Brazil, Turkey, Iran, and South Africa was found to be considerably important. While many people in the world die with undamaged organs, many other people die needing those organs. Therefore, it is considered that the collaborations and thus multidisciplinary studies about BD should be increased in the world countries, and the countries should be involved in bigger collaborations instead of little clusters. Especially, Muslim countries should be encouraged to do research and publish studies about the issues of brain death and organ transplantation.

Brain Deaths and Donors in an Education and Research Hospital

BACKGROUND

We aimed to define the causes of brain death (BD), criteria, and tests used for diagnosis, rates of family consent, and rates of organ donation in intensive care units (ICUs) of an education and research hospital.

METHODS

The data of patients with BD diagnosis in 7 years in our hospital was collected from an electronic database and archives retrospectively consisting of the demographic data, the causes of BD, criteria, and the tests used for diagnosis, family consent, and organ donation rates.

RESULTS

A total of 210 patients with BD diagnosis were enrolled in the study. There was a decline in number of patients with BD diagnosis between 2012 (54.76%) and 2018 (17.64%) in the neurology and neurosurgery ICU, while it increased from 35.71% in 2012 to 70.6% in 2018 in the general ICU. The most common cause of hospitalization for BD was spontaneous intracranial hemorrhage (43.8%). A total of 47.6% of brain-dead patients who did not qualify for organ donation were resuscitated unnecessarily after cardiac death. In 2012, diagnosis was always supported by ancillary tests, while in 2018, a total of 35.29% of the patients were diagnosed solely by clinical examination; 23.8% of patients' families had given consent for organ donation, and 19.53% of 210 patients became donors.

CONCLUSION

Physicians should be aware that patients with poor neurologic outcome can be candidates of BD donation, and careful examination and rapid diagnosis is crucial. All segments of society and the health care professionals should be informed and updated about organ donation and BD regularly to raise the numbers of organ donation.

Cardiac Dysrhythmias during Donor Care

Organ procurement coordinators must treat various cardiac dysrhythmias (arrhythmias), including rhythm disturbances that may cause or follow a cardiac arrest, in about 15% to 50% of donors. Treatment decisions should be based on the particular dysrhythmia and its effect on donor blood pressure. Medications selected should be effective but short acting. In this article, data available in publications located through a PubMed search are reviewed and specific dysrhythmias that are likely to occur during donor care are described. Treatment recommendations are based on guidelines from the American Heart Association.

Lived Experiences of Iranian Nurses Caring for Brain Death Organ Donor Patients: Caring as "Halo of Ambiguity and Doubt"

Background:

Brain death is a concept in which its criteria have been expressed as documentations in Harvard Committee of Brain Death. The various perceptions of caregiver nurses for brain death patients may have effect on the chance of converting potential donors into actual organ donors.

Objective:

The present study has been conducted in order to perceive the experiences of nurses in care-giving to the brain death of organ donor patients.

Methods:

This qualitative study was carried out by means of Heidegger’s hermeneutic phenomenology. Eight nurses who have been working in ICU were interviewed. The semi-structured interviews were recorded by a tape-recorder and the given texts were transcribed and the analyses were done by Van-Mannen methodology and (thematic) analysis.

Results:

One of the foremost themes extracted from this study included ‘Halo of ambiguity and doubt’ that comprised of two sub-themes of ‘having unreasonable hope’ and ‘Conservative acceptance of brain death’. The unreasonable hope included lack of trust (uncertainty) in diagnosis and verification of brain death, passing through denial wall, and avoidance from explicit and direct disclosure of brain death in patients’ family. In this investigation, the nurses were involved in a type of ambiguity and doubt in care-giving to the potentially brain death of organ donor patients, which were also evident in their interaction with patients’ family and for this reason, they did not definitely announce the brain death and so far they hoped for treatment of the given patient. Such confusion and hesitance both caused annoyance of nurses and strengthening the denial of patients’ family to be exposed to death.

Conclusion:

The results of this study reveal the fundamental perceived care-giving of brain death in organ donor patients and led to developing some strategies to improve care-giving and achievement in donation of the given organ and necessity for presentation of educational and supportive services for nurses might become more evident than ever.

Cardio-pulmonary resuscitation of brain-dead organ donors: a literature review and suggestions for practice

"Organ preserving cardiopulmonary resuscitation (OP-CPR)" is defined as the use of CPR in cases of cardiac arrest to preserve organs for transplantation, rather than to revive the patient. Is it ethical to provide OP-CPR in a brain-dead organ donor to save organs that would otherwise be lost? To answer this question, we review the literature on brain-dead organ donors, conduct an ethical analysis, and make recommendations. We conclude that OP-CPR can benefit patients and families by fulfilling the wish to donate. However, it is an aggressive procedure that can cause physical damage to patients, and risks psychological harm to families and healthcare professionals. In a brain-dead organ donor, OP-CPR is acceptable without specific informed consent to OP-CPR, although advance discussion with next of kin regarding this possibility is strongly advised. In a patient where brain death is yet to be determined, but there is known wish for organ donation, OP-CPR would only be acceptable with a specific informed consent from the next of kin. When futility of treatment has not been established or it is as yet unknown if the patient wished to be an organ donor then OP-CPR should be prohibited, in order to avoid any conflict of interest.

Hypothalamic-Pituitary Function in Brain Death: A Review

The Uniform Determination of Death Act (UDDA) states that an individual is dead when "all functions of the entire brain" have ceased irreversibly. However, it has been questioned whether some functions of the hypothalamus, particularly osmoregulation, can continue after the clinical diagnosis of brain death (BD). In order to learn whether parts of the hypothalamus can continue to function after the diagnosis of BD, we performed 2 separate systematic searches of the MEDLINE database, corresponding to the functions of the posterior and anterior pituitary. No meta-analysis is possible due to nonuniformity in the clinical literature. However, some modest generalizations can reasonably be drawn from a narrative review and from anatomic considerations that explain why these findings should be expected. We found evidence suggesting the preservation of hypothalamic function, including secretion of hypophysiotropic hormones, responsiveness to anterior pituitary stimulation, and osmoregulation, in a substantial proportion of patients declared dead by neurological criteria. We discuss several possible explanations for these findings. We conclude by suggesting that additional clinical research with strict inclusion criteria is necessary and further that a more nuanced and forthright public dialogue is needed, particularly since standard diagnostic practices and the UDDA may not be entirely in accord.

Unexpected fatal hypernatremia after successful cardiopulmonary resuscitation with therapeutic hypothermia: a case report

Central diabetes insipidus (DI), characterized by unexpected fatal hypernatremia, is a rare complication after successful cardiopulmonary resuscitation with therapeutic hypothermia, but may be potentially fatal if recognition is delayed. We describe here a patient who experienced cardiac arrest due to a pulmonary embolism, followed by successful resuscitation after induction of therapeutic hypothermia. The patient, however, suddenly developed unexpected hypernatremia with increased urine output and was diagnosed with central DI as a complication of cerebral edema, and eventually died. Our findings suggest that central DI should be considered as a possible complication following unexpected hypernatremia with increased urine output during therapeutic hypothermia and that desmopressin acetate should be used to treat central DI.

Circulatory arrest in a brain-dead organ donor: is the use of cardiac compression permissible?

Care of the brain-dead patient is common in intensive care practice. Aggressive donor management is advocated to increase supply of viable organs. Significant controversy exists over cardiac resuscitation in patients determined dead by cardiac criteria. The issue, till now, has not been addressed in brain dead patients. We discuss a case of cardiac resuscitation of a brain-dead donor to ensure organ donation. This case allows us to examine the use of brain death criteria to declare death, the controversy regarding cardiac resuscitation in organ donor patients, and the standards for use of cardiac resuscitation in the organ donor declared dead by brain death criteria. The consent process for organ donation in brain dead patients should address the possibility of subsequent cardiac arrest.

The Transplantable Organ Shortage in Singapore – Has Implementation of Presumed Consent to Organ Donation Made a Difference

The success of solid organ transplantation in the treatment of end-stage organ failure has fuelled a growing demand for transplantable organs worldwide that has far outstripped the supply from brain dead heart-beating donors. In Singapore, this has resulted in long waiting lists of patients for transplantable organs, especially kidneys. The Human Organ Transplant Act, introduced in 1987, is an opt-out scheme that presumes consent to removal of certain organs for transplantation upon death. Despite this legislation, the number of deceased organ donors in Singapore, at 7 to 9 per million population per year, remains low compared to many other developed countries. In this paper, we reviewed the clinical challenges and ethical dilemmas encountered in managing and identifying potential donors in the neurological intensive care unit (ICU) of a major general hospital in Singapore. The large variance in donor actualisation rates among local restructured hospitals, at 0% to 56.6% (median 8.8%), suggests that considerable room still exists for improvement. To address this, local hospitals need to review their processes and adopt changes and best practices that will ensure earlier identification of potential donors, avoid undue delays in diagnosing brain death, and provide optimal care of multi-organ donors to reduce donor loss from medical failures. Key words: Brain death, End-of-life, Multi-organ donor, Organ procurement, Opt-out

Intravascular Temperature Control System to Maintain Normothermia in Organ Donors

INTRODUCTION

Temperature regulation in humans is controlled by the hypothalamus. After death by neurological criteria, the hypothalamus ceases to function and poikilothermia ensues. Preservation of normothermia in those patients destined to become organ donors is an important part of maintaining the normal physiology of the organs and organ systems. Typical means of achieving normothermia include increasing the temperature of the ambient air, infrared warming lights, instillation of warmed intravenous fluids, and warm air or water blankets.

METHODS

In this prospective case series of five organ donors, we used an intravascular temperature modulation catheter (Alsius, Irvine, CA) to maintain normothermia in organ donors declared dead by neurological criteria. Data on accuracy of temperature maintenance at 37 degrees C and nursing ease of use were collected.

RESULTS

This intravascular temperature modulation catheter provided an accurate method of temperature regulation in brain death donor and easier to use from a nursing workload perspective.

CONCLUSIONS

Intravascular warming is a viable method for the maintenance of normothermia in organ donors. The experience here provides some insight into the ability of these devices to warm patients in other clinical situations.

Organ donations and unused potential donations in traumatic brain injury, subarachnoid haemorrhage and intracerebral haemorrhage

OBJECTIVE

To obtain insight into the occurrence of brain death and the potential for brain dead and controlled non-heart-beating organ donors (CNHB) in patients with traumatic brain injury (TBI), subarachnoid haemorrhage (SAH) and intracerebral haemorrhage (ICH) in a large neurosurgical serving area (2.1 million inhabitants).

DESIGN

Retrospective analysis of data concerning patients with TBI, SAH and ICH who died during the course of ICU treatment during 1999-2003.

SETTING

A 16-bed neuro-intensive care unit.

PATIENTS

Patients with TBI, SAH or ICH who died during the course of ICU treatment.

MEASUREMENTS AND RESULTS

The number of ICU deaths in patients with TBI, SAH and ICH declined from 111 in 1999 to 64 in 2003. In total, 476 deaths occurred. Of these, 177 patients were not included in the analysis. Two hundred ninety-nine (299) ventilated patients had two or more absent brainstem reflexes (ABSR) and a Glasgow Coma Score of 3-4 at the moment of treatment withdrawal and formed the potential for organ donation; 61 of these patients were treated until full brain death. Organs of 57 patients could be harvested. We analysed the reasons that organs were not procured in the 242 remaining patients. The most important reasons were family refusal (32%), medical contraindications (14%), and the treating physician not considering potential organ donation (20%). The missed potential is 162/299 (54%).

CONCLUSIONS

The number of actual and potential organ donors is declining, but a considerable number of potential CNHB donors exists. Refusal by relatives is the most important reason for failure to procure organs.